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● Speech Recognition Turning words By Jon Handler, M.D. D

espite the strong push for EHRs created by market forces and the HITECH act, much of medical

documentation today is still done through transcription. T ere are great reasons for using transcription. It is highly effi cient and creates an information-rich and tre- mendously eff ective vehicle for human communication. However, transcrip-

tion has historically been tarred with the reputation that human abstractors are needed to transform the data into computer-readable codes to support secondary uses such as analytics, re- porting, decision support, billing, and research and quality initiatives. T is is eff ective, but costly and time consum- ing. If the existing documentation is not complete enough to support these uses, then the abstractors must

engage with the clinicians to “fi ll in the blanks.” T is further increases costs and delays. Can we reap the benefi ts of tran-

scription’s unique ability to support clinical care while also supporting the various secondary uses of the data and still avoid the costs and delays of human abstraction? Transcription is ultimately a transaction between the person creating the documenta- tion and the downstream consumers of that docu- mentation. Even docu- ment creators eventu- ally consume their own documentation. We need to make sure that both ends of the process have the support they need to succeed. Today’s tech- nologies fi nally make that possible, and a number of institutions are already embarking on “end-to- end transcription.” With end-to-end tran- scription, they are build- ing systems that display a patient’s lifetime history of problems, medications, allergies and other clinical information. T is infor- mation is collated and neatly organized into an


into action End-to-end transcription is changing everything we thought we knew about creating clinical documentation.

Jon Handler, M.D., is chief medical information officer, M*Modal. For more on M*Modal: www.

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